everything you need to know about reimbursement for guide everything you need to know about...

Download Everything You Need to Know About Reimbursement For   GUIDE Everything You Need to Know About Reimbursement For OMIDRIA

Post on 13-Mar-2018

223 views

Category:

Documents

7 download

Embed Size (px)

TRANSCRIPT

  • REIMBURSEMENT GUIDE

    Everything You Need to Know About Reimbursement For OMIDRIA

  • 2

    About OMIDRIA

    OMIDRIA is the first and only FDA-approved drug that provides continuous intracameral delivery of NSAID and mydriatic/ anti-miotic therapy during cataract surgery1

    OMIDRIA contains a non-steroidal anti-inflammatory drug, ketorolac, to prevent miosis and to reduce postoperative pain and an a1-adrenergic receptor

    agonist, phenylephrine, to maintain ocular pupil diameter

    OMIDRIA is easy to integrate into operating procedures:

    Added preoperatively to irrigation solution1

    No other preparation required

    OMIDRIA is supplied as a concentrate in a clear, glass, single-patient-use vial

    containing 4-mL of sterile solution1

    OMIDRIA is reimbursed per vial, not per mL. Therefore, providers should use one

    vial as the billing unit

    INDICATIONS AND USAGEOMIDRIA is added to ophthalmic irrigation solution used during cataract surgery or intraocular lens replacement and is indicated for maintaining pupil size by preventing intraoperative miosis and reducing postoperative ocular pain.

    IMPORTANT SAFETY INFORMATIONOMIDRIA (phenylephrine and ketorolac injection) 1% / 0.3% must be added to irrigation solution prior to intraocular use.

    OMIDRIA is contraindicated in patients with a known hypersensitivity to any of its ingredients. Systemic exposure of phenylephrine may cause elevations in blood pressure.

    Use OMIDRIA with caution in individuals who have previously exhibited sensitivities to acetylsalicylic acid, phenylacetic acid derivatives, and other non-steroidal anti-inflammatory drugs (NSAIDs), or have a past medical history of asthma.

  • Please see the Full Prescribing Information for OMIDRIA.

    About This Guide

    This guide provides information on pass-through, OMIDRIA coding, OMIDRIA reimbursement, and more This guide is designed to facilitate timely reimbursement by standardizing claim

    submissions and ensuring appropriate reimbursement through proper billing and product coding*

    Coverage and payment may vary by payer, contractual agreements, and site of service

    * Information contained in this guide is provided as a reference for obtaining appropriate and accurate reimbursement for the use of OMIDRIA in eligible patients. Omeros does not guarantee reimbursement. OMIDRIAssure program services are subject to change without notice.

    OMIDRIA has a unique billing code

    C9447 Injection, phenylephrine and ketorolac, 4 ml vial

    Important reminders

    The OMIDRIAssure comprehensive reimbursement program provides assistance for financially eligible uninsured or government-insured patients and those with insufficient commercial insurance*

    Questions related to a patients benefits or eligibility for cataract surgery or OMIDRIA should be addressed by calling the OMIDRIAssure Live Assistance Information Hotline at 1-877-OMIDRIA (1-877-664-3742), contacting your Omeros representative, or working directly with your payer provider representative

    Consult your facility-specific payer contracts to determine whether OMIDRIA is paid separately from the packaged payment for cataract surgery

    IMPORTANT SAFETY INFORMATION The most commonly reported adverse reactions at 2-24% are eye irritation, posterior capsule opacification, increased intraocular pressure, and anterior chamber inflammation.

    Use of OMIDRIA in children has not been established.

    Please see the Full Prescribing Information for OMIDRIA.

    You are encouraged to report Suspected Adverse Reactions to the FDA. Visit www.fda.gov/medwatch, or call 1-800-FDA-1088.

  • 4

    Medicare Part B Pass-through status allows reimbursement for OMIDRIA separate from the packaged

    Ambulatory Payment Classification (APC) reimbursement for the surgical procedure

    For pass-through drugs, Centers for Medicare & Medicaid Services (CMS) sets the payment rate at Average Selling Price (ASP) plus 6%

    Check the CMS website for current quarterly payment rates in the Hospital OPPS (Addendum B) or ASC Payments (Addendum BB) section

    Payment rates are updated quarterly by CMS and, during the government sequester, 6% is reduced to 4.3%

    There is no patient co-payment for OMIDRIA in the HOPD setting. In the ASC setting, the patient may be subject to a 20% co-payment

    Approximately 90% of Medicare Part B patients have some form of supplemental/secondary insurance that covers co-payments3,

    For government-insured patients with an uncovered out-of-pocket expense and who meet certain financial criteria, Omeros has established the Equal Access Patient Assistance Program as part of OMIDRIAssure, which allows patients to receive OMIDRIA at no cost; a free vial is sent to your facility prior to surgery

    About Medicare Billing and Reimbursement

    Pass-through status for OMIDRIA allows ASCs and HOPDs to bill Medicare and other payers for OMIDRIA using a Healthcare Common Procedure Coding System (HCPCS) code unique to OMIDRIA C9447 Injection, phenylephrine and ketorolac, 4 ml vial. The payment is over and above the facility fees paid to ASCs or to HOPDs for cataract surgery.

    CY 2017 HCPCS and APC codes for OMIDRIA2

    CY 2017 HCPCS CY 2017 long descriptor CY 2017 APC

    C9447 Injection, phenylephrine and ketorolac, 4 ml vial 1663

    *Status Indicator

    Based on currently available information and subject to change without notice. Individual plan coverage, policies, and procedures may vary and should be confirmed. Omeros does not guarantee coverage or payment.

    To be eligible for the Equal Access Patient Assistance Program, patients must be enrolled prior to surgery. For any patient eligible for the Equal Access Patient Assistance Program, (1) the facility receives a free vial of OMIDRIA prior to surgery and (2) the patients insurance carrier(s) should not be billed for OMIDRIA. OMIDRIAssure program services are subject to change without notice.

  • Please see the Full Prescribing Information for OMIDRIA.

    Medicare Part C (Medicare Advantage) Like traditional Medicare Part B, Medicare Advantage plans will cover OMIDRIA, but

    the payment rate may differ from traditional Part B or be subject to payer-specific facility contractual limitations

    For a Medicare Advantage patient, the specific Medicare Advantage payer should be contacted in advance to determine the level of reimbursement for OMIDRIA

    About Medicare Billing and Reimbursement

    * To be eligible for the Equal Access Patient Assistance Program, patients must be enrolled prior to surgery. For any patient eligible for the Equal Access Patient Assistance Program, (1) the facility receives a free vial of OMIDRIA prior to surgery and (2) the patients insurance carrier(s) should not be billed for OMIDRIA. OMIDRIAssure program services are subject to change without notice.

    EQUAL ACCESS

    PATIENT ASSISTANCE PROGRAM*

    Assistance for financially eligible uninsured or government-insured patients

    Eligible patients* will receive OMIDRIA at no cost

    Free vial will be sent to your facility prior to surgery

    Application for free vial must be submitted 5 days prior to date of surgery

    Please visit www.OMIDRIAssure.com for more details and to start enrolling patients today

    For personalized help, call the OMIDRIAssure Live Assistance Information Hotline at 1-877-OMIDRIA (1-877-664-3742) 9 am6 pm ET, MondayFriday

  • 6

    About Commercial Insurance Billing and Reimbursement

    Check if facility-specific payer contracts allow for separate payment of drugs, new technologies, and pass-through drugs

    Confirm and verify payer payment/fee schedules for OMIDRIA

    Verify acceptance of C-code and payer-specific use of appropriate revenue code

    WE PAY THE DIFFERENCE COMMERCIALLY INSURED PATIENT REIMBURSEMENT PROGRAM

    Assistance for patients with insufficient commercial insurance Omeros will pay your facility, on behalf of your patient, the difference between your

    facilitys acquisition cost for OMIDRIA and the amount covered by your patients insurance*

    The benefits of OMIDRIAssure apply even if the annual commercial deductible obligation has not yet been met

    Please visit www.OMIDRIAssure.com for more details and to start enrolling patients today

    For personalized help, call the OMIDRIAssure Live Assistance Hotline at 1-877-OMIDRIA (1-877-664-3742) 9 am6 pm ET, MondayFriday

    Payer Contracts: Best Practices for Medicare Advantage** and Commercial Payers

    * OMIDRIAssure program services are subject to change without notice. The We Pay The Difference Commercial Reimbursement Program patient benefit is not available for patients with any government insurance. Omeros does not guarantee reimbursement.

    ** Coverage and payment varies by Medicare Advantage plans.

  • Please see the Full Prescribing Information for OMIDRIA.

    Helpful hints: best practices for claim submissions in general Make sure submissions are timely and accurate

    Double-check codes and units

    Verify Diagnosis codes and procedure codes

    CPT, HCPCS, and revenue codes

    NDC (depending on claim form)

    Stay up to date on the payer and billing and coding trends

    Pay close attention and double-check your work when creating claims

    Follow up with payers after claims are submitted

    About Commercial Insurance Billing and Reimbursement

    Patient insurance benefits should be thought of in terms of primary and additional coverage to determine billable status Work with Omeros Reimbursement Team to determine billable status for your

Recommended

View more >